Provider Demographics
NPI:1407283989
Name:AZALEA PHARMACY LLC
Entity Type:Organization
Organization Name:AZALEA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-334-2411
Mailing Address - Street 1:1801 GOVERNMENT ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3942
Mailing Address - Country:US
Mailing Address - Phone:228-818-5111
Mailing Address - Fax:
Practice Address - Street 1:1019 GOVERNMENT ST
Practice Address - Street 2:SUITE F
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3860
Practice Address - Country:US
Practice Address - Phone:228-818-5111
Practice Address - Fax:228-818-5113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12664/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy